Florida must fight harder in war on Medicaid fraud

Published: Tuesday, November 27, 2012 at 5:30 a.m.

Last Modified: Monday, November 26, 2012 at 5:30 p.m.

Florida has a major fraud problem in the Medicaid health care program. What it needs in response is a strong anti-fraud unit and a program that moves recipients into managed care.

Attorney General Pam Bondi, who came into office almost two years ago, has been working on expanding the size and scope of Medicaid fraud investigations. But she needs some help.

Here's why: Florida and the federal government spend a total of $21.2 billion on Medicaid. Yet the state spends a paltry $25 million on fraud prevention and detection. That's a tiny fraction of just 1 percent of Florida's Medicaid spending.

According to Florida Trend magazine, the attorney general and the Florida Agency for Health Care Administration have a combined 300 investigators. But they only made 85 arrests in 2011 and 28 arrests through August of 2012. The state has received 6,800 fraud complaints so far this year.

Medicaid is jointly funded by the state and the federal government. Medicaid has been gobbling up more and more of the state budget as it speeds toward being one-third of our state budget. Florida now spends more on Medicaid than public education.

In Gov. Rick Scott's last budget presentation, the situation was spelled out in dire terms.

"(Medicaid) is bankrupting virtually all states in the nation," Scott said in his budget proposal for the fiscal year of 2012-2013. "Since 2000, Florida's Medicaid program has grown from $7.7 billion to a projected $21.5 billion, a 180 percent increase."

To keep those costs from devouring the state budget, Medicaid needs major reforms that ensure that patients receive efficient and effective care. Fraud prevention and prosecution is only part of the solution to spiraling costs, but fraud cannot be ignored.

In December 2011, the Florida Agency for Health Care Administration issued a report on its Medicaid fraud efforts. The report shows the state can grab back cash it lost from even reputable providers because they overcharge.

But the state can do much more. The state averages fewer than two arrests per year per investigator in the Medicaid fraud units. That ranks Florida at 36 out of 50 states in terms of fraud prosecution.

So the Legislature and the governor need to better fund and articulate the missions of the attorney general's fraud control squad and the Agency for Health Care Administration's fraud unit. State leaders should also look at combining the fraud control units, as complaints of interagency miscommunication are numerous. Other states prosecute Medicaid fraud far more effectively than Florida.

The agencies are using technology better, but they must expand that effort. In its December 2011 report, the Agency for Health Care Administration cited efforts to "data mine." That is, to sort through digital Medicaid claims, using statistical models and sophisticated programming to uncover patterns of fraud or other billing aberrations.

This effort shows great promise, although it should not be seen as an eventual replacement for forensic accountants or human investigators.

Perhaps the most important element in combating fraud is proper management of patient care. The state needs an expansive Medicaid managed care program, with private insurers taking responsibility for costs.

Private insurers have a powerful incentive to run Medicaid efficiently and fraud-free. The state has a five-county pilot initiative, and in 2011, the Legislature passed such legislation for the entire Medicaid program. But Florida still awaits federal approval of the managed care program.

Aggressive fraud detection and prosecution, combined with managed care for Medicaid recipients, should eliminate most of Florida's Medicaid fraud problem. State and federal officials must resolve to put an end to giving away public money to crooks under the compassionate cover of providing health care for the less fortunate.

<p>Florida has a major fraud problem in the Medicaid health care program. What it needs in response is a strong anti-fraud unit and a program that moves recipients into managed care. </p><p>Attorney General Pam Bondi, who came into office almost two years ago, has been working on expanding the size and scope of Medicaid fraud investigations. But she needs some help. </p><p>Here's why: Florida and the federal government spend a total of $21.2 billion on Medicaid. Yet the state spends a paltry $25 million on fraud prevention and detection. That's a tiny fraction of just 1 percent of Florida's Medicaid spending. </p><p>According to Florida Trend magazine, the attorney general and the Florida Agency for Health Care Administration have a combined 300 investigators. But they only made 85 arrests in 2011 and 28 arrests through August of 2012. The state has received 6,800 fraud complaints so far this year. </p><p>Medicaid is jointly funded by the state and the federal government. Medicaid has been gobbling up more and more of the state budget as it speeds toward being one-third of our state budget. Florida now spends more on Medicaid than public education. </p><p>In Gov. Rick Scott's last budget presentation, the situation was spelled out in dire terms. </p><p>"(Medicaid) is bankrupting virtually all states in the nation," Scott said in his budget proposal for the fiscal year of 2012-2013. "Since 2000, Florida's Medicaid program has grown from $7.7 billion to a projected $21.5 billion, a 180 percent increase." </p><p>To keep those costs from devouring the state budget, Medicaid needs major reforms that ensure that patients receive efficient and effective care. Fraud prevention and prosecution is only part of the solution to spiraling costs, but fraud cannot be ignored. </p><p>In December 2011, the Florida Agency for Health Care Administration issued a report on its Medicaid fraud efforts. The report shows the state can grab back cash it lost from even reputable providers because they overcharge. </p><p>But the state can do much more. The state averages fewer than two arrests per year per investigator in the Medicaid fraud units. That ranks Florida at 36 out of 50 states in terms of fraud prosecution. </p><p>So the Legislature and the governor need to better fund and articulate the missions of the attorney general's fraud control squad and the Agency for Health Care Administration's fraud unit. State leaders should also look at combining the fraud control units, as complaints of interagency miscommunication are numerous. Other states prosecute Medicaid fraud far more effectively than Florida. </p><p>The agencies are using technology better, but they must expand that effort. In its December 2011 report, the Agency for Health Care Administration cited efforts to "data mine." That is, to sort through digital Medicaid claims, using statistical models and sophisticated programming to uncover patterns of fraud or other billing aberrations. </p><p>This effort shows great promise, although it should not be seen as an eventual replacement for forensic accountants or human investigators. </p><p>Perhaps the most important element in combating fraud is proper management of patient care. The state needs an expansive Medicaid managed care program, with private insurers taking responsibility for costs. </p><p>Private insurers have a powerful incentive to run Medicaid efficiently and fraud-free. The state has a five-county pilot initiative, and in 2011, the Legislature passed such legislation for the entire Medicaid program. But Florida still awaits federal approval of the managed care program. </p><p>Aggressive fraud detection and prosecution, combined with managed care for Medicaid recipients, should eliminate most of Florida's Medicaid fraud problem. State and federal officials must resolve to put an end to giving away public money to crooks under the compassionate cover of providing health care for the less fortunate.</p>